A mosquito bite that leaves healthcare in shivers

“If disease is an expression of individual life under unfavourable conditions, then epidemics must be indicative of mass disturbances in mass life,” the influential German physician and statesman Rudolph Virchow had said.

By that yardstick Delhi’s experience with chikungunya and dengue tells us a discomforting story. The Capital recorded its first death from chikungunya this week, and the toll from these mosquito-borne diseases has only been rising.

But given that malaria, dengue and chikungunya are “seasonal”, displaying a typical pattern in their spread, it is baffling why the country’s best hospitals get overwhelmed, again and again.

Blame it on the neglect of public health principles and urban mis-planning, say public health experts, unequivocally. “It is the arrogance of cities, that we have the resources and we can get it when we want it,” says Yogesh Jain of Jan Swasthya Sahyog. The present situation is a direct consequence of poor public health preventive measures, bad management of water resources and homes, he says. Despite access to the AIIMS (All India Institute of Medical Sciences), with a thousand doctors staying on the campus and another 5,000 staffing it, the facility gets overwhelmed, says Jain, who was with AIIMS for about 17 years.

An epidemic is a “marker of man made upheavals,” he says, pointing to the absence of “mosquito proofing” when plans are made to dig up roads and lay LPG or telephone lines, for instance. People don’t have water supply, so they are forced to store water, again a breeding ground for mosquitoes.

But there is little use in acting only when there is a public health outbreak, says Amit Sengupta of Jan Swasthya Abhiyan. In a month, the present crisis will go away thanks to an increase in herd immunity, a change in the weather, and reduced water logging, he says. And this will mean the issue goes off public discourse and planning. The confounding aspect of Delhi’s crisis is that it happens despite having the best public healthcare facilities and being the seat of State and Central governments. In fact, that’s part of the problem, Sengupta says, as multiple agencies governing the city don’t co-ordinate. They need to work together and include private hospitals in plans to provide such facilities free of cost, he says.

Epidemics have their own curve, says Jain, and once they cross a tipping point, they take a different curve where little can be done except to manage them. But authorities cannot always be crisis managers.

The preventive plan should be for bio-environment control, fogging, distribution of bednets, besides quick and effective treatment. The effort should be to control the vector (mosquito), or the disease causing agent, and the host (human). That includes limiting further transmission from an already infected person to an uninfected population.

Dengue and chikungunya require fever and pain management, unless the patient has an existing medical condition or complications (low blood platelets) develop, explains Jain.

Contrasting the situation with Sri Lanka, recently declared “malaria free”, Jain stresses the importance of having a plan and sticking to it. But for that surveillance needs to be dynamic so you know what you are planning for, he says, referring to the absence of accurate data on these illnesses.

World Health Organisation’s India Chief Henk Bekedam makes a similar point on strengthening surveillance. Disease-related information, he said, needs to be captured from private hospitals as well to be able to better map the country’s disease burden.

"Surveillance for dengue and chikungunya in India presently captures only those patients that are laboratory confirmed at government identified sentinel hospitals, most of these are in the public sector,” says a media report quoting him.

The silver lining that can emerge from this epidemic, says Jain, is if it leads to some public health preparedness. “We need to show we are smart first before our cities become smart,” he says, dismayed at the inability to control these vector-borne diseases.